Gendered drug policy: Motherisk and the regulation of mothering in Canada

Women, gender and drugs: between research and action

This article is part of Harm Reduction Journal's special issue on harm reduction research in the francophone context and specifically the Harm Reduction Network (HARENE). After highlighting the history and current context of harm reduction for women in France, we present the results of four research studies addressing the links between gender and drugs which were presented in the book Espaces genrés des drogues. Parcours dans la fête, l'intimité et la réduction des risques ('Gendered Spaces of Drugs. A journey of intimacy, party and harm reduction'). This article is divided into three parts, each addressing a specific space: the space of institutional care, the intimate marital space, and the urban festive space. We begin by describing gender inequalities within harm reduction and care structures, by demonstrating how single-sex spaces facilitate the care of women, and how care professionals can perpetuate unequal gender norms in their relationship with a woman in a situation of addiction expressing a desire for pregnancy. Concerning the marital space, we highlight the reproduction of gender norms within socially included heterosexual couples who use drugs and are socially included, particularly concerning the choice of the intimate partner, the distribution of tasks linked to the purchase and sale of drugs, and parenthood. Finally, concerning the festive space, the article highlights the differentiated strategies of men and women in urban festive places, and the maintenance of a gendered order of festive places and drug consumption. This leads us to discuss the current issues of stigmatization of women drug users, and the initiatives put in place in the French context to promote harm reduction for women who use drugs.

Association between socioeconomic and motherhood characteristics with receiving community-based treatment services among justice-involved young female drug users: a retrospective cohort study in Taiwan

BACKGROUND

Drug-involved individuals who contact treatment services in Taiwan are mostly driven by criminal justice systems either as an alternative or adjunct to criminal sanctions for a drug offence. With a focus on justice-involved young female drug users, the present study examines the extent to which socioeconomic and motherhood characteristics are associated with receiving deferred prosecution, a scheme diverting drug offenders to community-based addiction treatment.

METHODS

We identified a cohort of 5869 women under the age of 30 arrested for using Schedule II drugs (primarily amphetamine-like stimulants) from the 2011-2017 National Police Criminal Records in Taiwan. Information concerning socioeconomic characteristics, pregnancy and live birth history, and deferred prosecution was obtained through linkage with the 2006-2019 National Health Insurance, birth registration, and deferred prosecution datasets. Multinomial logistic regression was used to evaluate the association with stratification by recidivism status.

RESULTS

Within six months of arrest, 21% of first-time offenders (n = 2645) received deferred prosecution and 23% received correction-based rehabilitation; the corresponding estimates for recidivists (n = 3224) were 6% and 15%, respectively. Among first-time offenders, low/unstable income was associated with lower odds of deferred prosecution (adjusted odds ratio [aOR] = 0.71; 95% CI: 0.58, 0.88). For recidivists, those with low/unstable income (aOR = 1.58) or unemployment (aOR = 1.58) had higher odds of correction-based rehabilitation; being pregnant at arrest was linked with reduced odds of deferred prosecution (aOR = 0.31, 95% CI: 0.13, 0.71) and correction-based rehabilitation (aOR = 0.50, 95% CI: 0.32, 0.77).

CONCLUSIONS

For the young women arrested for drug offences, disadvantaged socioeconomic conditions were generally unfavored by the diversion to treatment in the community. Childbearing upon arrest may lower not only the odds of receiving medical treatment but also correctional intervention. The criminal prosecution policy and process should be informed by female drug offenders' need for treatment and recovery.

'Planning for a healthy baby and a healthy pregnancy': A critical analysis of Canadian clinical practice guidelines for the treatment of opioid dependence during pregnancy

As opioid fatalities rise in North America, the need to improve the supports available to those who are dependent on opioids and pregnant has become more urgent. This paper discusses the social organisation of drug treatment supports for those who are pregnant, using Canadian clinical practice guidelines (CPGs) for methadone maintenance treatment (MMT) as a case study. Pregnant patients are a priority population for MMT, both in Canada and internationally; the regulatory bodies that oversee MMT in Canada are the provincial Colleges of Physician and Surgeons and Health Canada. The paper analyses MMT CPGs published by these agencies, comparing their general recommendations to those specific to pregnant patients. We demonstrate that the guidelines address few treatment considerations for pregnant patients, other than improved birth outcomes and child welfare, despite acknowledging their more complex needs. Drawing on social science studies of gender and drugs, we argue that MMT CPGs therefore perpetuate the intensified surveillance and foetal prioritisation that have long generated barriers to care for opiate-dependent pregnant patients. We also discuss how and why the CPGs ultimately only reinforced these current limitations in the drug treatment sector.

Outcomes and experiences after child custody loss among mothers who use drugs: A mixed studies systematic review

BACKGROUND

Mothers who use drugs are more likely to experience child custody loss than mothers who do not use drugs. The negative impact of removal on children has been well characterized in current literature while less is known about the impact of custody loss on mothers. The purpose of this mixed studies systematic review is to describe the state of science on the maternal outcomes and experiences after child custody loss among mothers who use drugs.

METHODS

PubMed, PsycINFO, CINAHL, and Social Work Abstract databases were systematically searched between June 2022 to January 2023. Article eligibility criteria centered on the outcomes and experiences of mothers who use drugs after losing child custody. Studies were analyzed using results-based convergent synthesis methodology for mixed studies reviews. Study quality was assessed using the Mixed Methods Appraisal Tool (MMAT). A visual synthesis model was derived from combined results across all studies.

RESULTS

Of 2434 articles screened, 22 relevant scientific articles were selected for inclusion. Longitudinal, cohort studies (n=4) and a cross-sectional study (n=1) identified positive associations between custody loss and poorer mental health, increased drug use and overdose risk, less treatment engagement, and worsened social factors. Qualitative studies (n=17) identified themes that described re-traumatization after child custody loss and the development of coping mechanisms through identity negotiation.

CONCLUSION

Our findings indicate that child custody loss associated with drug use may exacerbate trauma and worsen maternal health. Immediate implications are provided for maternal health policy and practice in healthcare, child welfare, and legal professions.

Academy of Breastfeeding Medicine Clinical Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder (Revised 2023)

Background: The Academy of Breastfeeding Medicine (ABM) revised the 2015 version of the substance use disorder (SUD) clinical protocol to review the evidence and provide updated literature-based recommendations related to breastfeeding in the setting of substance use and SUD treatments. Key Information: Decisions around breastfeeding are an important aspect of care during the peripartum period, and there are specific benefits and risks for substance-exposed mother-infant dyads. Recommendations: This protocol provides breastfeeding recommendations in the setting of nonprescribed opioid, stimulant, sedative-hypnotic, alcohol, nicotine, and cannabis use, and SUD treatments. Additionally, we offer guidance on the utility of toxicology testing in breastfeeding recommendations. Individual programs and institutions should establish consistent breastfeeding approaches that mitigate bias, facilitate consistency, and empower mothers with SUD. For specific breastfeeding recommendations, given the complexity of breastfeeding in mothers with SUD, individualized care plans should be created in partnership with the patient and multidisciplinary team with appropriate clinical support and follow-up. In general, breastfeeding is recommended among mothers who stop nonprescribed substance use by the time of delivery, and they should continue to receive ongoing postpartum care, such as lactation support and SUD treatment. Overall, enhancing breastfeeding education regarding substance use in pregnancy and lactation is essential to allow for patient-centered guidance.

The Alberta Neonatal Abstinence Syndrome Mother-Baby Care ImprovEmeNT (NASCENT) program: protocol for a stepped wedge cluster randomized trial of a hospital-level Neonatal Abstinence Syndrome rooming-in intervention

BACKGROUND

Neonatal Abstinence Syndrome (NAS), a problem common in newborns exposed to substances in-utero, is an emerging health concern. In traditional models of care, infants with NAS are routinely separated from their mothers and admitted to the Neonatal Intensive Care Unit (NICU) with long, expensive length of stay (LOS). Research shows a rooming-in approach (keeping mothers and infants together in hospital) with referral support is a safe and effective model of care in managing NAS. The model's key components are facilitating 24-h care by mothers on post-partum or pediatric units with support for breastfeeding, transition home, and access to Opioid Dependency Programs (ODP). This study will implement the rooming-in approach at eight hospitals across one Canadian Province; support practice and culture shift; identify and test the essential elements for effective implementation; and assess the implementation's impact/outcomes.

METHODS

A stepped wedge cluster randomized trial will be used to evaluate the implementation of an evidence-based rooming-in approach in the postpartum period for infants born to mothers who report opioid use during pregnancy. Baseline data will be collected and compared to post-implementation data. Six-month assessment of maternal and child health and an economic evaluation of cost savings will be conducted. Additionally, barriers and facilitators of the rooming-in model of care within the unique context of each site and across sites will be explored pre-, during, and post-implementation using theory-informed surveys, interviews, and focus groups with care teams and parents. A formative evaluation will examine the complex contextual factors and conditions that influence readiness and sustainability and inform the design of tailored interventions to facilitate capacity building for effective implementation.

DISCUSSION

The primary expected outcome is reduced NICU LOS. Secondary expected outcomes include decreased rates of pharmacological management of NAS and child apprehension, increased maternal ODP participation, and improved 6-month outcomes for mothers and infants. Moreover, the NASCENT program will generate the detailed, multi-site evidence needed to accelerate the uptake, scale, and spread of this evidence-based intervention throughout Alberta, leading to more appropriate and effective care and use of healthcare resources.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT0522662. Registered February 4^th, 2022.

Women who use drugs: engagement in practices of harm reduction care

BACKGROUND

Harm reduction services that employ or are operated by people who use drugs are an effective means of mitigating overdose risks and other drug-related harms. However, stereotypes portraying people who use criminalized drugs as incapable caregivers persist. This is especially true for women who use drugs, and to a greater extent racialized women, who are characterized as having diverged from traditional ideals of womanhood as a result of drug-user stigma and the intersections of gender- and class-based and racist stereotypes. In an effort to identify and understand how women who use drugs practise care through harm reduction, we explored the experiences of women accessing a low-threshold supervised consumption site exclusively for women (transgender and non-binary inclusive) in Vancouver, Canada.

METHODS

Data were drawn from research conducted from May 2017 to June 2018 exploring women's experiences accessing the supervised consumption site during an overdose crisis. Data included forty-five semistructured interviews with women recruited from the site, analysed thematically to explore practices of care through harm reduction.

FINDINGS

Participants reported engaging in both formal and informal care. Acts of care included interventions that both aligned with and deviated from conventional understandings of care practices, including overdose reversal and education, overdose supervision/care, and assisted injection.

CONCLUSION

The boundary between formal and informal harm reduction care is fluid. Women who use drugs engage in harm reduction across these borders with acts of care that align with or fill the gaps in current harm reduction services in order to meet the needs of drug-using communities, challenging negative stereotypes of women who use drugs. However, these caregiving practices can increase risks to care providers' physical, mental, and emotional health and wellness. Increased financial, social, and institutional supports, including safer supply, assisted injection, and community resources, are needed to better support women as they continue to engage in harm reduction care.

Between Care and Control: Examining Surveillance Practices in Harm Reduction

As harm reduction programs and services proliferate, people who use drugs (PWUD) are increasingly subjected to surveillance through the collection of their personal information, systematic observation, and other means. The data generated from these practices are frequently repurposed across various institutional sites for clinical, evaluative, epidemiological, and administrative uses. Rationales provided for increased surveillance include the more effective provision of care, service optimization, risk stratification, and efficiency in resource allocation. With this in mind, our reflective essay draws on empirical analysis of work within harm reduction services and movements to reflect critically on the impacts and implications of surveillance expansion. While we argue that many surveillance practices are not inherently problematic or harmful, the unchecked expansion of surveillance under a banner of health and harm reduction may contribute to decreased uptake of services, rationing and conditionalities tied to service access, the potential deepening of health disparities amongst some PWUD, and an overlay of health and criminal-legal systems. In this context, surveillance relies on the enlistment of a range of therapeutic actors and reflects the permeable boundary between care and control. We thus call for a broader critical dialogue within harm reduction on the problems and potential impacts posed by surveillance in service settings, the end to data sharing of health information with law enforcement and other criminal legal actors, and deference to the stated need among PWUD for meaningful anonymity when accessing harm reduction and health services.

Spotting as a risk mitigation method: A qualitative study comparing organization-based and informal methods

OBJECTIVES

To explore the similarities and differences of organization-based and informal spotting (remote supervision of substance use) from the perspectives of spotters and spottees across Canada.

METHODS

Spotters and spottees who spot informally and for organizations were recruited across Ontario and Nova Scotia. We interviewed 20 informal and 10 organization-based participants by phone using semi-structured interviews between 08/2020 and 11/2020. Participants were asked about each methods benefits and limitations. Interviews were audio-recorded, transcribed, and analyzed thematically.

RESULTS

Benefits of informal spotting included its ability to strengthen social connections and foster autonomy in overdose response planning. The lack of support for informal spotters created stress and burnout. Organization-based spotters enjoyed the spotting training and support provided. However, regulations surrounding having to call ambulance in overdose events deterred many people from wanting to work for or call these services.

CONCLUSIONS

Both organization-based and informal spotting have a role in mitigating harms associated with the overdose crisis. Moving forward, further research is needed on how to optimize these services for all people who use drugs in varying jurisdictions internationally.

Child-centred harm reduction

Harm reduction has become increasingly influential in drug policy and practice, but has developed primarily around adult drug use. Theoretical, practical, ethical and legal issues pertaining to children and adolescents under the age of majority - both relating to their own use and the effects of drug use among parents or within the family - are less clear. This commentary proposes a sub-field of drug policy at the intersection of harm reduction and childhood which we refer to as 'child-centred harm reduction'. We provide a definition and conceptual model, as well as illustrative questions that emerge through a child-centred harm reduction lens. Many people in different countries are already working on these kinds of issues, whose work needs greater recognition, analysis and support. In beginning to name and define this sub-field we hope to improve this situation, and inspire further international debate, collaboration, and innovation.

COVID-19 and the opportunity for gender-responsive virtual and remote substance use treatment and harm reduction services

The COVID-19 pandemic has increased the uptake of virtual and remote service delivery in the substance use field, which was previously uncommon. This swift uptake of virtual services provides an opportunity to improve service design to meet the diverse needs of women and gender-diverse people. Such services have the potential to better meet the needs of women and gender-diverse people by allowing for increased choice, control, and autonomy, enabling empowerment, facilitating greater considerations of power relations, violence, childcare responsibilities, and fostering greater inclusion of trans and non-binary people. This commentary aims to identify how virtual and remote delivery of substance use treatment and harm reduction services can be gender-responsive. We highlight the role gender transformative services play in meeting the unique needs of women and gender-diverse people who use drugs both during and after the COVID-19 pandemic. By using the unique window of opportunity COVID-19 has created to develop and deliver gender-transformative programs, we can help address the detrimental gaps in service accessibility and effectiveness that have persistently been experienced by women and gender-diverse people who use drugs.

Redefining Child Protection: Addressing the Harms of Structural Racism and Punitive Approaches for Birthing People, Dyads, and Families Affected by Substance Use

There has been growing attention on the effect of substance use, including opioid use disorder, on pregnant and birthing people and their infants. Although effective medication treatment for opioid use disorder is the standard of care, racial disparities are evident in access during pregnancy. Structural racism affects treatment access and approaches to reporting to child welfare services. Black people and their newborns are more likely to be drug tested in medical settings, and Black newborns are more likely to be reported to child welfare services. Child welfare models often focus on substance use as being the dominant issue that drives risk for abuse or neglect of a child, and current reporting practices, which vary by state, contribute to these disparities. This commentary proposes an alternate way of thinking about family-based support. We suggest changes to law, institutional policy, clinical care, and ideology. Specifically, we propose realigning around shared goals of supporting the birthing person-infant dyad and recognizing that substance use is not synonymous with abuse or neglect; creating an anonymous notification process outside of the child welfare system to meet federal data-collection requirements; limiting perinatal drug testing and requiring written, informed consent for parental and neonatal testing; and developing integrated care teams and hospital settings and policies that support dyadic care.

Policy actor views on structural vulnerability in harm reduction and policymaking for illegal drugs: A qualitative study

BACKGROUND

Health risks associated with drug use are concentrated amongst structurally vulnerable people who use illegal drugs (PWUD). We described how Canadian policy actors view structural vulnerability in relation to harm reduction and policymaking for illegal drugs, and what solutions they suggest to reduce structural vulnerability for PWUD.

METHODS

The Canadian Harm Reduction Policy Project is a mixed-method, multiple case study. The qualitative component included 73 semi-structured interviews conducted with harm reduction policy actors across Canada's 13 provinces and territories between November 2016 and December 2017. Interviews explored perspectives on harm reduction and illegal drug policies and the conditions that facilitate or constrain policy change. Our sub-analysis utilized a two-step inductive analytic process. First, we identified transcript segments that discussed structural vulnerability or analogous terms. Second, we conducted latent content analysis on the identified excerpts to generate main findings.

RESULTS

The central role of structural vulnerability (including poverty, unstable/lack of housing, racialization) in driving harm for PWUD was acknowledged by participants in all provinces and territories. Criminalization, in particular, was seen as a major contributor to structural vulnerability by justifying formal and informal sanctions against drug use and, by extension, PWUD. Many participants expressed that their personal understanding of harm reduction included addressing the structural conditions facing PWUD, yet identified that formal government harm reduction policies focused solely on drug use rather than structural factors. Participants identified several potential policy solutions to intervene on structural vulnerability including decriminalization, safer supply, and enacting policies encompassing all health and social sectors.

CONCLUSIONS

Structural vulnerability is salient within Canadian policy actors' discourses; however, formal government policies are seen as falling short of addressing the structural conditions of PWUD. Decriminalization and safer supply have the potential to mitigate immediate structural vulnerability of PWUD while policies evolve to advance social, economic, and cultural equity.

Mothers Who Use Drugs: Closing the Gaps in Harm Reduction Response Amidst the Dual Epidemics of Overdose and Violence in a Canadian Urban Setting

Objectives. To identify key gaps in overdose prevention interventions for mothers who use drugs and the paradoxical impact of institutional practices that can increase overdose risk in the context of punitive drug policies and a toxic drug supply. Methods. Semistructured interviews were conducted with 40 women accessing 2 women-only, low-barrier supervised consumption sites in Greater Vancouver, British Columbia, Canada, between 2017 and 2019. Our analysis drew on intersectional understandings of structural, everyday, and symbolic violence. Results. Participants' substance use and overdose risk (e.g., injecting alone) was shaped by fear of institutional and partner scrutiny and loss (or feared loss) of child custody or reunification. Findings indicate that punitive policies and institutional practices that frame women who use drugs as unfit parents continue to negatively shape the lives of women, most significantly among Indigenous participants. Conclusions. Nonpunitive policies, including access to safe, nontoxic drug supplies, are critical first steps to decreasing women's overdose risk alongside gender-specific and culturally informed harm-reduction responses, including community-based, peer-led initiatives to maintain parent-child relationships. (Am J Public Health. 2022;112(S2):S191-S198. https://doi.org/10.2105/AJPH.2022.306776).

Pregnant and early parenting Indigenous women who use substances in Canada: A scoping review of health and social issues, supports, and strategies

This study reviews and synthesizes the literature on Indigenous women who are pregnant/early parenting and using substances in Canada to understand the scope and state of knowledge to inform research with the Aboriginal Health and Wellness Centre of Winnipeg in Manitoba and the development of a pilot Indigenous doula program. A scoping review was performed searching ten relevant databases, including one for gray literature. We analyzed 56 articles/documents. Themes include: (1) cyclical repercussions of state removal of Indigenous children from their families; (2) compounding barriers and inequities; (3) prevalence and different types of substance use; and (4) intervention strategies. Recommendations for future research are identified and discussed.

Reimagining Research with Pregnant Women and Parents Who Consume Cannabis in the Era of Legalization: The Value of Integrating Intersectional Feminist and Participatory Action Approaches

Research on women who consume cannabis has predominantly focused on the perinatal period whereby cannabis consumption is problematized, linked to negative perinatal outcomes, and related to substance use and mental health challenges. When this historical literature and research about cannabis consumption is considered through a sociolegal and intersectional lens, questions emerge about how cannabis legalization may benefit and harm women, particularly women who experience marginalization along various axes of identity such as gender, race, and class. Questions also emerge about how women who consume cannabis may be perceived, represented, and treated as part of health and social care practices, particularly while pregnant and parenting. This commentary seeks to untangle what could be at stake for pregnant women and mothers, and what could be emphasized in future research endeavors, in the new era of cannabis legalization in Canada. The authors encourage research initiatives that attend to and reimagine harm reduction philosophies, and that integrate intersectional, feminist, and participatory action research approaches.

"They went down that road, and they get it": A qualitative study of peer support worker roles within perinatal substance use programs

BACKGROUND

Perinatal substance use programs employ multidisciplinary teams to support women who use drugs through pregnancies and parenting, with some programs expanding to include peer support workers with lived experience of parenting and substance use. Research has shown peer support to enhance care in substance use treatment; however, little research exists that examines this model of support within perinatal substance use programs. We explore the current and potential role of peer support workers within perinatal substance use programs, from the perspectives of mothers accessing these programs.

METHODS

We conducted focus groups with 20 mothers enrolled in three perinatal substance use programs serving the greater Vancouver area, including two community-based programs that employed peer workers and an acute care maternity ward that did not. We recorded focus groups, had them professionally transcribed, and analyzed them thematically.

RESULTS

Participants characterized peer support workers as extending and complementing informal care practices already occurring within programs, including mother-to-mother support with breastfeeding, childcare, and system navigation. Integrating peer workers shifted care relations and practices in ways that participants found beneficial. Participants emphasized how support workers with similar social locations and life experiences-beyond just their substance use-helped to foster trust and safety for mothers in the program. Indigenous mothers discussed the importance of having Indigenous support workers whose practice is grounded in their cultures and experiences under colonization. Participants ascribed an aspirational status to peer support workers, conveying that it was motivational to see other mothers working in the program, and described the role as a means of maintaining connection and community. However, some expressed concerns about managing professional-personal boundaries and being emotionally "triggered" by the work.

CONCLUSION

This study evidences benefits of employing peer support workers within perinatal substance use programs, while also indicating the need for organizational processes to ensure that peer staff are integrated equitably and supported adequately.

Heroin and the illegal drug overdose death epidemic: A history of missed opportunities and resistance

BACKGROUND

Due to prohibitionist policies and practices, a poisoned illegal drug supply, and inadequate access to flexible substitution programs, Canada is currently experiencing the worst illegal drug overdose death epidemic in its history. In examining past policies, practices, and discourse that support heroin regulation and drug prohibition, the drivers of the current illegal drug overdose death epidemic in Canada are brought more clearly into focus.

METHODS

This article provides a critical socio-historical analysis of heroin (opioid) regulation with a focus on Canadian federal and provincial policies in the province of B.C., especially the city of Vancouver. Drawing from primary and secondary sources, this article provides a critical socio-historical analysis of heroin (opioid) regulation in Canada.

RESULTS

Examining Canada's history of heroin criminalization provides a window to understand the systemic discrimination against people who use illegal heroin and other opioids. From its inception, heroin prohibition has worked to brutally punish a small segment of the population, especially those who are poor, racialized, and gendered. Negative heroin discourse and stereotyping about people who use heroin had an effect, shaping drug law, policing, prisons, and policy and treatment options.

CONCLUSION

Little attention has been given to the increase in heroin possession offences across Canada over nine consecutive years and the lack of heroin substitution programs. Resistance to drug prohibition and criminal approaches to drug use emerged in the 1950s and continue today. Those most affected by drug policies demand inclusion and representation, access to a legal heroin supply, and the establishment and maintenance of heroin buyer clubs, contesting the very foundations of drug control in the twenty-first century.

Overdose among mothers: The association between child removal and unintentional drug overdose in a longitudinal cohort of marginalised women in Canada

BACKGROUND

Accidental overdose is a major public health concern in North America with research primarily focused on cisgender men. Little is known about the burden of overdose among marginalised women, particularly in the context of child custody loss. This study aims to examine the prevalence of overdose and the association with child removal in a cohort of marginalised women.

METHODS

This study draws on a merged dataset (2010-2018) of two community-based longitudinal cohorts of over 1000 marginalised women in Canada recruited using time-location sampling. After restricting to women who had ever had a live birth, bivariate and multivariable logistic regression using generalised estimating equations (GEE) were used to examine the association between child removal and overdose. Joint effects of child removal and Indigeneity were also investigated.

RESULTS

Of the 696 women who reported ever having a live birth, 39.7% (n = 276) reported child removal at baseline. Unintended, non-fatal overdose rates were high, with 35.1% (n = 244) of women reporting ever having an overdose. Using bivariate GEE analyses, having a child apprehended and being Indigenous were positively correlated with overdose. Using multivariable GEE, child removal increased the odds of overdose by 55% (AOR: 1.55; 95% CI 1.01-2.39) after adjusting for education and Indigenous ancestry. Using multivariable joint-effects analysis, Indigenous women who had experienced child removal had over twice the odds of an unintended overdose than non-Indigenous women who had not lost custody after adjusting for education, food insecurity, and sex work (AOR: 2.09; 95% CI 1.15-3.79).

CONCLUSION

This analysis suggests that, after controlling for known confounders, women who have a child removed experience higher odds of overdose, and these odds are highest among Indigenous women. The high prevalence of overdose in this cohort suggests the need for further strategies to prevent overdose among pregnant and parenting women.

"Bed Bugs and Beyond": An ethnographic analysis of North America's first women-only supervised drug consumption site

BACKGROUND

Attention to how women are differentially impacted within harm reduction environments is salient amidst North America's overdose crisis. Harm reduction interventions are typically 'gender-neutral', thus failing to address the systemic and everyday racialized and gendered discrimination, stigma, and violence extending into service settings and limiting some women's access. Such dynamics highlight the significance of North America's first low-threshold supervised consumption site exclusively for women (transgender and non-binary inclusive), SisterSpace, in Vancouver, Canada. This study explores women's lived experiences of this unique harm reduction intervention.

METHODS

Ethnographic research was conducted from May 2017 to June 2018 to explore women's experiences with SisterSpace in Vancouver's Downtown Eastside, an epicenter of Canada's overdose crisis. Data include more than 100 hours of ethnographic fieldwork, including unstructured conversations with structurally vulnerable women who use illegal drugs, and in-depth interviews with 45 women recruited from this site. Data were analyzed in NVivo by drawing on deductive and inductive approaches.

FINDINGS

The setting (non-institutional), operational policies (no men; inclusive), and environment (diversity of structurally vulnerable women who use illegal drugs), constituted a space affording participants a temporary reprieve from some forms of stigma and discrimination, gendered and social violence and drug-related harms, including overdose. SisterSpace fostered a sense of safety and subjective autonomy (though structurally constrained) among those often defined as 'deviant' and 'victims', enabling knowledge-sharing of experiences through a gendered lens.

CONCLUSION

SisterSpace demonstrates the value and effectiveness of initiatives that engage with socio-structural factors beyond the often narrow focus of overdose prevention and that account for the complex social relations that constitute such initiatives. In the context of structural inequities, criminalization, and an overdose crisis, SisterSpace represents an innovative approach to harm reduction that accounts for situations of gender inequality not being met by mixed-gender services, with relevance to other settings.

(Re)shaping the self: An ethnographic study of the embodied and spatial practices of women who use drugs

While gendered experiences of drug use have been well-established, understanding how women resist structures that constrain their agency is important for mitigating drug-related harms, especially as overdose has become North America's leading cause of accidental death. Drawing on the intersectional risk environments of WWUD, this ethnographic study examined how gendered expectations of women's drug use, appearance, and comportment influenced vulnerability to overdose within the context of a fentanyl-driven overdose crisis. This community-engaged ethnography, conducted in Vancouver, Canada from May 2017 to December 2018, included in-depth interviews with 35 marginally-housed WWUD (transgender-inclusive) and approximately 100 h of fieldwork in single room accommodation (SRA) housing and an established street-based drug scene. Data were analyzed thematically with attention to embodiment, agency, and intersectionality. Findings highlight how gendered expectations and normative violence impacted women's use of space, both in the drug scene and SRAs. To resist efforts to 'discipline' their bodies, participants engaged in situated gender performances. Physical appearance was also deemed critical to managing drug use disclosure. Participants adopted gendered embodied practices, including altered consumption methods or injecting in less visible areas, to conceal their use from peers and at times, their partners. To resist harms associated with involuntary disclosure, participants often used alone in SRAs or in public spaces. While such practices allowed women to exert agency within constraining systems, they concurrently heightened overdose risk. Findings demonstrate how women engaged in everyday acts of resistance through embodied drug use practices, which increased their agency but elevated overdose risk. Implementing gender-specific programs that increase bodily agency and control (e.g. low-threshold services for personal care, women-focused harm reduction support) are needed to reduce risk of overdose for WWUD.

Women's utilization of housing-based overdose prevention sites in Vancouver, Canada: An ethnographic study

BACKGROUND

In response to a fentanyl-driven overdose crisis, low-threshold supervised consumption sites, termed overdose prevention sites (OPS), have been rapidly implemented in Vancouver, Canada. Since approximately 88% of fatal overdoses in the province occur indoors, OPS have been integrated into select non-profit-operated single room accommodations (SRA) housing. We examined the social-structural features of these housing-based OPS (HOPS) on women's overdose risk.

METHODS

Ethnographic research was conducted from May 2017 to December 2018 in Vancouver. Data included 35 in-depth interviews with women who use drugs living in SRAs and approximately 100 h of observational fieldwork in SRAs and surrounding areas. Data were analyzed using an intersectional risk environment approach, with attention to equity and violence.

FINDINGS

Findings demonstrate that the social and structural environments of HOPS created barriers for women to access these interventions, resulting in an increased overdose risk. Primary barriers included uncertainty as to who else was accessing HOPS, rules prohibiting smoking, and a lack of trust in staff's abilities to effectively respond to an overdose. Most participants considered HOPS to be unsafe environments, and expressed fear of violence from residents and/or guests. The perceived risk of violence was informed by previous experiences of assault and the witnessing of violence. Many participants thus consumed drugs alone in their rooms to better control their safety, despite heightened overdose risk. Further, most participants did not perceive themselves to be at risk of an overdose due to drug use practices and tolerance levels, and viewed using alone as a safer option than HOPS.

CONCLUSION

Findings highlight how the low-barrier design and operation of HOPS can undermine women's engagement with HOPS. Overdose prevention strategies in SRAs should also include gender-specific models (e.g. women-only HOPS, women peer workers) to help mitigate barriers to these services within the context of the current overdose crisis.